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REVIEW ARTICLE
Year : 2022 | Volume
: 49
| Issue : 3 | Page : 233-241
Success Rate of Reimplantation of Avulsed Primary Anterior Teeth in Children: A Systematic Review
Krishna S Kadam, Niraj S Gokhale, Shivayogi M Hugar, Riddhi Joshi, Nivedita Saxena Neha Kohli
Department of Paediatric and Preventive Dentistry, KAHER'S, KLE VK Institute of Dental Sciences, Belagavi, Karnataka, India
Correspondence Address:
Dr. Niraj S Gokhale
Department of Paediatric and Preventive Dentistry, KAHER'S, KLE VK Institute of Dental Sciences, Belagavi, Karnataka
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jss.jss_64_22
Background: Avulsion of tooth is a grave traumatic injury that is associated with complete displacement from its socket. Lack of conclusive solid evidence and discord opinion is the main reason for the dentist to abstain reimplantation of avulsed primary teeth in children and there are hardy few case reports associated with it. A detailed systematic investigation of literature involving several databases is required to obtain additional evidence for the same. Aim: This systematic review aimed for emphasizing risks and benefits to guide dentists in implementing the best clinical decision for cases of reimplanting avulsed primary teeth. Method: A systematic search was conducted in databases PubMed, Cochrane, and Google Scholar (Embase) for the studies published from January 1, 2010, to December 31, 2021. Cross-references of the selected articles were also done by hand and electronic searching. Gray literature was also searched for the studies according to the relevance. Results: Through search strategy, 4623 articles were yielded. After screening through titles and abstracts, 46 articles remained which were further screened for full text. In the end, 8 articles were included in the systematic review according to the eligibility criteria. Conclusion: This systematic review concluded that reimplantation can be carried out in primary dentition too by following proper and immediate treatment protocols; however, adequate clinical studies are utmost required with longer follow-up for the establishment of substantial evidence that can usher clinicians regarding elite approach in treatment of primary tooth avulsion.
Keywords: Avulsion, dental trauma, primary anterior teeth, reimplantation
Dental trauma is considered a serious problem among children, with most injuries requiring complete assessment and management of luxation injuries that are mainly associated with the resilience of alveolar bone and supporting structures.[1] Primary dentition plays a decisive role in functional and psychological aspects of a child's development. The introduction of pediatric dental practices for toddlers and babies has contributed to newer studies that focused on traumatic injuries in primary dentition.[2] Researches have established that dental trauma to primary dentition can cause serious damage to the succedaneous dentition in cases of avulsion.[3]
Avulsion of tooth is a grave traumatic injury coupled with complete displacement from its socket. Traumatic dental injuries in primary dentition do not promote reimplantation of avulsed primary teeth as it was stated that “primary teeth should be given to tooth fairy and heroic methods designed to maintain primary incisor following trauma should be discouraged.”[4] However, concern of parents for missing teeth of their child has urged pediatric dentists to perform reimplantation.
The prevalent endorsement to refrain from reimplantation of primary incisor seems to be mainly based on opinions and conventions rather than on full proof evidence.[5] There is not much literature found and there are only few case reports associated with reimplantation of primary teeth. The trepidation of being liable for causing injury to permanent teeth is the main reason for avoiding this procedure, and the degree of harm caused due to reimplantation remains obscure.[6]
The dentist should be optimistic and perform reimplantation of primary teeth rather than being recusant and relying on anecdotal evidence from literature.[7]
Thus, a detailed and systematic investigation of literature involving several databases is required to obtain further evidence in replantation of avulsed primary teeth and allow the trustworthy empirical dental practice. Thus, this study aims to perform a systematic review with a focused question, “Should an avulsed primary tooth be reimplanted back into the socket?” which mainly emphasizes on risks and benefits to guide dentists in implementing the best clinical decision for such cases.
MethodsProtocol and registration
The review was registered in PROSPERO, an International Prospective Register of Systematic Reviews funded by the National Institute of Health Research and produced by Centre for Reviews and Dissemination [CRD]). The registration number of this review is CRD42020212131 and can be accessed on the website http://www.crd.york.ac. uk/prospero/index.php.
In our systematic review, population included was children with the age group of 1–6 years, intervention was to include reimplantation of an avulsed primary tooth whose comparison was done with avulsed tooth which was not reimplanted and outcome was to evaluate success rate of reimplanted primary teeth.
The objective of our systematic review was to evaluate the clinical and radiographic outcomes of reimplantation of avulsed primary teeth in children.
Eligibility criteria
Inclusion criteria
The study setting should be clinical
Study design should be randomized control trials, quasi-randomized control clinical trial, retrospective or a cohort study, case series, and case reports
The study population should be children between 1 and 6 years of age with primary teeth.
Study assessing the efficiency of reimplantation of avulsed primary teeth
A study was published between January 1, 2010, and December 31, 2021
Studies written in the English language and studies written in any other language but are possible to get translated into English.
Exclusion criteria
Studies conducted on animalsThe article was reported as a review and systematic reviewParticipants aged above 6 years of ageStudies on reimplanted avulsed permanent teeth.Literature search and search strategy
Search strategies
The literature search strategy was developed using keywords related to Reimplantation, replantation, reimplant, deciduous, primary, avulsion, and children. Data were searched through the databases such as PubMed, Google Scholar (Embase), Web of Science, and Cochrane from January 1, 2010, to December 31, 2021. Detailed items including search strategies used, no of articles searched, and selected are illustrated in [Table 1]. Cross-references were checked for relevant articles, and gray literature was also searched on the efficiency and outcomes of the replanted avulsed primary tooth. Hand searching of articles was done when the full texts of the relevant studies were not available through an electronic database.
Study selection
One review author (KSK) screened the titles and abstracts obtained by search strategy and included them if they met the inclusion criteria. Later, full texts of all the included studies were obtained. After obtaining the full texts of the articles, they were screened by reading the whole article and then decided if they met the inclusion criteria. Whenever there was uncertainty regarding any study to be eligible for inclusion, the problem was resolved by discussing it with the second author (NSG). For the inclusion of articles for meta-analysis, the quality assessment of each article was done by the author (KSK) independently and later it was crosschecked by one other author (SMH). Finally, the search yielded 8 studies to be included in the systematic review. All the excluded studies were recorded with the reason for exclusion for each study. None of the authors were blinded to the journal titles, study authors, or the institutions where the studies were conducted.
Data extraction (study characteristics)
A standardized data extraction form was primed in Microsoft Excel and 2–3 entries were made reviewed by an expert [Table 2]. Any divergence between the authors was resolved by discussion. The following criteria were predetermined for extracting the data:
Table 2: Qualitative analysis of the studies selected for the systematic reviewThe key interest was to check for a clinical success rate of the reimplanted avulsed primary toothEvaluation for a radiographical success rate of the reimplanted avulsed primary tooth.Risk of bias
The risk of bias for nonrandomized studies was done using the modified Newcastle–Ottawa Quality assessment form [Table 3].[8]
Table 3: Quality assessment of studies using a Newcastle-Ottawa Scale[14]Meta-analysis
Only a few case reports with a small sample size were included; hence, there will be no meta-analysis that is performed.
ResultsThe result of our search strategy identified 4583 articles through database searching in Cochrane, PubMed, and Google Scholar. Total 4623 articles were retrieved. The second step was screening through titles, after which 4543 articles were excluded because they did not meet the objectives of the systematic review. Eighty articles that remained were screened for duplicates through Endnote Software VersionX7 (Niles Software, Clarivate, Emeryville, California, United States of America). Out of 80, 12 articles were found to be duplicated, and thus, the remaining 68 articles were screened through abstracts subsequently. Through abstract screening, 22 articles were excluded as they did not meet the eligibility criteria. Finally, 46 articles were screened for a full text out, of which 38 were excluded [Figure 1].
Finally, 8 articles were selected which were case reports. All the studies were then qualitatively analyzed, after which they were included in the systematic review.
DiscussionSummary of evidence
The best way to replenish the lost tooth is by replacing it with itself. Children are unaware of the loss of primary incisor before age 5 or 6 as it does not make a considerable difference to them as their associates also have lost their incisors. The parents being concerned about such a situation are eager to replant the tooth as they worry about the child's esthetic appearance.[9] Very few studies have been conducted throughout the world to reimplant avulsed primary tooth as an only fear is of being accused of causing damage to the permanent teeth. Lack of clear and reasonable guidelines and of long-term studies showing a high success rate has also been contributed to the dentist's decision to avoid replantation.[1]
Sequelae
Case reports chosen in the systematic review based on the inclusion and exclusion criteria mentioned anatomic and histological deviations due to injuries to developing permanent tooth bud after reimplantation of the avulsed primary tooth which was mainly:
Root hypoplasiaRoot duplicationExternal root resorption.Root hypoplasia
The traumatic injuries to primary dentition are associated with adverse repercussions in permanent dentition. The abnormalities seen in root due to interruption in root formation without any coronal abnormalities are relatively rare. The main cause for this is endorsed to the stage of root development indirectly affecting development of Hertwig's epithelial root sheath. Radiographic examination reveals typical foreshortening of the root. Root resorption may also be seen with this type of root abnormality.[3]
The same type of finding has been observed in the case report which showed traumatic injury to 51, 52, 61, 62 leading to avulsion, root hypoplasia without coronal malformation with 11, 21. Since the trauma occurred at 4 years and 8 months, the crown remained unaffected.[5],[10]
Root duplication
This is a rare occurrence, seen subsequent to intrusive luxation of primary teeth. This complication is usually the outcome of an injury at a time when half or less than half of the crown is developed.[11] The pathology of these cases indicates that a traumatic division of the cervical loop occurring at the time of injury, thereby forming two separate roots. Another etiology could be the fusion of the permanent tooth bud with supernumerary tooth forming a joint tooth with confluent dentin. Radiographically, a mesial and distal root can be demonstrated which extends from a partially formed crown. One case report demonstrated that reimplantation of a primary tooth could result in damage to the tooth bud of the permanent tooth leading to unusual morphology of the root of the permanent tooth.[10]
External root resorption
External root resorption in replanted teeth is said to be a surface, inflammatory, or replacement resorption, of which only inflammatory resorption is associated with infected and necrotic pulp.[12] Damage to the root surface results in exposure of dentinal tubules, hence paving a way for entry of microbes and toxins from root canal via exposed dentinal tubules to enter adjoining periodontal tissues aggravating inflammation and progressive root resorption. This resorption seems to be incessant in immature teeth, mainly due to thin dentinal walls and wide tubules. However, prescription of systemic antibiotics which may prevent the occurrence of inflammatory resorption in replanted teeth still remains matter of debate.[13] However, once bacteria have made their way and established a concrete base in necrotic pulp, the arrest or healing of inflammatory resorption depends only on the removal of bacteria by endodontic therapy.
Progressive external resorption associated with inflammatory changes in the surrounding tissue, may occur years after injury and is mainly seen located near the cementoenamel junction and lateral to apical one-third of the root resulting in shortening of the root.[14] In its advanced stages, resorption may undermine the crown and become clinically evident as a pink spot below the cervical enamel, in both vital and root-filled teeth. The etiological factor could be the presence of bacteria in the gingival crevice and their penetration into dentinal tubules, exposed by active or poorly repaired resorption.[15] This may cause inflammation in the area and elicit progressive root resorption, sometimes interfering with the ankylosing processes. Radiographically, external inflammatory root resorption is associated with progressive loss of tooth substance and persistent radiolucency in the adjoining alveolar bone. The censorious time for the onset of these changes seems to be about 2–8 weeks after injury. Endodontic therapy is advocated with conspicuous clinical and radiographic signs of pulp necrosis and inflammatory resorption.[7]
In the case report, traumatic injury to 61 led to avulsion of the tooth and was followed by reimplantation of the same. Evidence of external root resorption was seen after 8 months which was slowly progressing; however, the reimplanted tooth was able to maintain arch integrity and esthetics with no morphological changes till the eruption of a permanent successor.[1],[10] In the case report, traumatic injury had led to avulsion of 51, 61 that was followed by reimplantation. It was observed that external root resorption was evident on apical third of the root which progressed with Grade I mobility following reimplantation of avulsed 51, 61 after 20 months. After 2 years and 3 months, the teeth were still in their position with no signs of pain or inflammation. After 3 years, the deciduous teeth exfoliated and successors erupted in their normal position. However, white spot lesions were noticed on mesial incisal edge on labial side of successors.[4]
Similar type of finding was seen in a case report where traumatic injury had led to avulsion of 51, 61. Evidence of external root resorption was seen after 45 days of tooth reimplantation with 61 which had gradually advanced when follow-up was done after 4 months. The patient reported with traumatic injury again after 4 months that might have also contributed for worsening the condition.[3]
Factors considered for successful replantation of avulsed tooth[11]
Phase of root formationTime elapsed between trauma and dental careStorage mediaLevel of contaminationExecution of tooth replantationPulp therapySplintingFollow-up.Phase of root formation
The stage of root development is an important factor to consider before performing reimplantation. The more mature the root formation, the thinner is the periodontal ligament (PDL) tissue. Thick PDL, purportedly, can tolerate a definite dry period before reimplantation. Evaporation kills the critical cell layers next to the cementum. Moreover, the removal of the PDL before replantation is followed by extensive replacement resorption.[5]
Time elapsed between trauma and dental care
The case reports included in our systematic review have mentioned that the best time for reimplantation of an avulsed tooth is within 30 min as it helps to maintain the viability of the PDL and for successful reimplantation.[16]
In cases with an extraoral dry period of 60 min or more, treatment of the tooth with sodium fluoride should be considered to primary or permanent teeth.[1],[10]
Remove the PDL and extirpate the pulpPlace the tooth in a 2.4% sodium fluoride solution acidulated to a pH of 5.5 for 20 minPerform pulp therapy extraorallyRemove the coagulum from the socketReplant the toothSplint the tooth for 4 weeksFollow-up: minimum 1 year.Storage media
Dry storage leads to cell necrosis and compromised healing. Teeth prevented from drying will heal with a normal ligament. In most of the cases, avulsed teeth have been either stored in mouth and in saline or tap water before reimplantation procedure is carried out. Tap water is detrimental to cell viability due to low osmolality of tap water, resulting in quick cell death.[17] Various studies have proved rather the overall success of reimplantation depends on extra alveolar time of tooth rather than storage media used. It is proposed that milk, saliva, blood, Hank's buffered salt solution saline as good storage media.[3],[4],[5],[6],[7],[8] The positive effect of saliva for shorter storage periods has also been documented. Placing the avulsed tooth in buccal vestibule or saliva did not significantly impair periodontal healing, while even short dry storage periods harmed the PDL.[2] It has also been recommended to store the tooth in saline by dissolving teaspoon of salt in 200 ml of water rather than carrying in gauze or any other cloth material.[6] Storage of avulsed tooth in saline for more than 1 h can have negative impact on viability of PDL cells even though it seems to be better than dry condition.[4]
Level of contamination
The extent of contamination of the root surface before replantation and the cleansing procedure was found to be highly significant for subsequent PDL healing events, a short rinsing with tap water or saline is recommended.[18] The case report also recommends that cleanliness of tooth and then reimplantation would help to maintain the viability of PDL.[5] Mechanical cleaning of root should be prevented as it removes the viable cells required for attachment of root to alveoli.[3]
Pulp therapy
It has been suggested that endodontic treatment should be done as avulsion disrupts vascular and nerve bundles with trouncing of blood supply to the tooth leading to necrosis. Thus, endodontic treatment should be done.[19] In the case of young primary teeth with wide-open apex, revascularization takes place on its own so it has been proposed that in such cases endodontic treatment is not necessary. In the case report where avulsed 63 was reimplanted, endodontic treatment was performed first followed by metapex obturation. It has been observed that endodontic treatment prior to reimplantation prevents development or progression of inflammatory root resorption.[7] The case report has highlighted the importance of root resection and retrograde instrumentation of the root canal system before performing replantation, debating that this procedure could protect the tooth germ of successor during reimplantation. If pulp therapy is not performed, pulp necrosis could develop and result in inflammatory root resorption, thereby affecting the apical bone tissue as well.[2]
Splinting
Prolonged splinting (i.e., more than 10 days) leads to a boost in replacement resorption. Movement during healing promotes healing with less ankylosis.[20] However, the case reports propose semirigid splinting with soft stainless-steel wire for 21 days which allows physiological tooth movement and allowing reattachment of PDL followed by oral hygiene instructions and a soft diet till the removal of the splint.[3],[4],[5],[6],[7]
The dentist should give apt advice to the parents and guardians as to how to go about during such emergency conditions. Avulsion is one of serious emergency in dentistry which should not be disregarded as it is rightly said, “Every natural tooth in man's head is more valuable than diamond.” Immediate reimplantation is the best treatment indeed, however if that cannot be carried out then alternatives to preserve the tooth like storage media can be utilized until it is brought in notice of dentists.[21]
Treatment protocol
At the site of an accident
If dirty, the tooth can be cleaned by simply rinsing it under running, cold tap water for 10 s and placing it immediately in its socket. This procedure has been found to decrease the extent of root resorption. It is proposed that if the replantation procedure cannot be performed at this time, the tooth can be stored in the patient's buccal vestibule.[1]
Avulsed teeth should always be replanted as soon as possible and if this is not possible a storage medium such as Hank's buffered salt solution, saliva, saline, or milk should be used to store the replanted tooth until the dentist is visited.[3],[7]
At the clinic
The case history should include exact information on the time delay between injury and replantation as well as the conditions under which the tooth has been stored.[22] An extended extraoral period– even dry storage– is not an absolute contraindication to replantation, as the root surface can be treated chemically to protract the resorption process in mature teeth.[23] If replantation is decided upon, the tooth is placed in saline. The case report mentions if a tooth is visibly contaminated, the root surface is rinsed with a stream of saline from a syringe until visible contaminants have been washed away, including around the apical foramen. The alveolus is also rinsed with a flow of saline to remove the contaminated coagulum. No effort should be made to sterilize or mechanically cleanse the root surface, as such procedures will damage or destroy vital periodontal tissue and cementum. In the case of an open apex, a pretreatment with tetracycline or APF gel is advised.[7] A case report also mentions dipping of avulsed tooth in a saline solution containing heparin (10 U/mL) and ampicillin (100 mg/mL). Here, endodontic treatment was not performed for 2 months, and direct reimplantation and splinting was done. To prevent coagulation of blood initially and facilitate revascularization the avulsed tooth were dipped in saline solution containing heparin.[4]
The socket is then examined. If there is evidence of fracture, it is essential to reposition the fractured bone by inserting an instrument in the socket and then modeling the bone. The tooth is replanted using light digital pressure. Only light pressure must be used during the replantation procedure, as this will permit detection of resistance from displaced alveolar bone fragments that impede replantation.[24] The replanted incisor should fit loosely in the alveolus to prevent further damage to the root surface. Rigid splinting of replanted mature and auto transplanted immature teeth increases the extent of root resorption. Replanted teeth should, therefore, only be splinted for a minimal period. One to two weeks are normally sufficient to ensure adequate periodontal support, as gingival fibers in the cervical region are already healed by this time. It is proposed that semirigid splinting with soft stainless-steel wire for 21 days can allow physiological tooth movement and allowing reattachment of the PDL.[3],[5],[7] Proper repositioning can now be evaluated by the occlusion and the tooth splinted to adjacent incisors. A radiograph is taken once the splint has been applied, to verify that the normal position of the tooth has been achieved.[1],[5]
When the splint is to be removed, it is important to remember that the replanted tooth is still rather loose. It is therefore important to remove the splinting material carefully, with finger support on the replanted tooth. Furthermore, if endodontic treatment is indicated, it should be carried out before splint removal.[1],[4],[5]
It is proposed in the case of a closed apical foramen, endodontic treatment should always be performed prophylactically, as pulp necrosis can be anticipated. Where the apical foramen is wide open and replantation has been performed within 3 h after injury, it is justifiable to await revascularization of the pulp.[11],[25] The case reports included in the systematic review did not mention the condition where extra–oral timing is more than 15 min, according to the International Association of Dental Traumatology guidelines, mature teeth with prolonged dry extra-alveolar periods (i.e., >1 h) be placed in a fluoride solution (2.4% sodium fluoride phosphate acidulated at pH 5.5) for 20 min before replantation. Before this, the necrotic PDL is removed with a scaler. After immersion in the fluoride solution, the root surface is rinsed with saline, the tooth is replanted, and then splinted for at least 1 week. The effect of this treatment seems to be a 50% reduction of the progression of root resorption of replanted teeth. One week is normally sufficient to ensure adequate periodontal support, as gingival fibers in the cervical region are already healed by this time. It has also been suggested that the root surface be treated with various substances, such as sodium fluoride, tetracycline, stannous fluoride, citric acid, hypochloric acid, calcium hydroxide, formalin, alcohol, diphosphonates, and indomethacin which inhibit root resorption.[3],[7]
Postoperative instructions[11],[13]
Diet which is soft in consistency is suggested till tooth is mobileMull over the use of antibioticsMaintain Oral hygieneThe parents should be advised to visit the dental clinic for periodic follow-up.Follow-up
Series of radiographs should be taken in follow-up period to diagnose any signs of root resorption. A period of 12–18 months is utmost necessary to manifest whether reimplantation was successful also, monitoring of esthetics is required to maintain self-esteem in children.[7],[11],[26] To assess the integrity of splint, first recall examination of the child should be done 24 h after replantation. After 2 weeks, mobility of the tooth should be checked and splint is removed; pulp therapy is performed (if not done at the first visit) followed by evaluation of oral hygiene.[26] The duration till the next follow-up depends on the findings of the previous checkup and its prognosis.[27] If no complications are suspected, the follow-ups can be recommended at 1, 3, and 6 months and then every 6 months.[28] It is advised that the duration of follow-ups should be extended until the eruption of the permanent successor. The sole purpose of the recall examination is not only the early detection of postoperative complications but also to diagnose the conditions that have the potential to evoke pathologies.[3],[5],[7],[10]
ConclusionWith the surge in research and ever increase in globalization, there is a paradigm shift regarding the use of conservative techniques in pediatric dentistry.[13],[29],[30] A million-dollar question still prevails on what the best possible way could be to treat and reimplant avulsed primary teeth. This systematic review has highlighted the various treatment regimens to be undertaken while reimplantation of avulsed primary teeth in children and rather than focusing on its negative outcome and sequelae, the dentists should rather focus on preserving the tooth and reimplanting the same. Such trauma cases should be carried out based on concrete evidence obtained through the scientific literature. Therefore, our systematic review is conducted for the management of avulsed primary tooth in children and to check its success rate. Hence, the systematic review concluded that reimplantation can be carried out in primary dentition too by following proper and immediate treatment protocols.
Why this paper is important to pediatric dentist?
Primary dentition plays a decisive role in functional and psychological aspects of a child's development where avulsion of tooth is a grave traumatic injury coupled with complete displacement from its socketThis systematic review mainly emphasizes on risks and benefits to guide dentists in implementing the best clinical decision in case of avulsion of primary teeth in childrenThis systematic review highlights the various treatment regimens that could be undertaken for preserving and maintaining the reimplanted tooth.Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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